Chapter 25: Suicide and Non-Suicidal Self

Chapter 25: Suicide and Non-Suicidal Self-Injury

Definition of Suicide

  • Suicide: An intentional act of killing oneself by any means.

  • Statistics:

    • Tenth leading cause of death in the US.

    • Fourth leading cause of death among children aged 10 to 14.

    • Third leading cause of death in the 15 to 24 age group.

    • Fourth leading cause of death in the 25 to 44 age group.

    • Eighth leading cause of death in ages 45 to 64.

Risk Factors for Suicide

  • Psychiatric Disorders: Mental health conditions significantly contribute to risk.

  • Substance Use Disorders: Use of alcohol or other substances increases risk.

  • Male Gender: Males are at a higher risk.

  • Increasing Age: Older adults show increased vulnerability.

  • Race: Certain racial groups may have higher incidences.

  • Religion: Religious beliefs can impact rates of suicide.

  • Marriage: Marital status can be a factor; being single or divorced may increase risk.

  • Profession: Certain professions may have higher risk levels.

  • Physical Health: Chronic illness or poor physical health is linked to higher risk.

Suicidal Behavior

  • Statistics:

    • Ranked as the 10th cause of death in the US (2014).

    • One person dies by suicide every 12.93 minutes.

    • The highest number of suicides in individuals aged 85 and older, followed by those aged 45-65.

  • Demographics:

    • More females attempt suicide than males.

    • Males die by suicide at a rate of 3.5 times higher than females in 2014.

    • There is an increase in firearm usage among women, associated with a 50% use rate.

Biological Factors

  • Genetics: Suicidal behavior tends to run in families, suggesting a hereditary aspect.

  • Neurotransmitters: Low levels of serotonin are associated with depressed mood, influencing suicidality.

Psychosocial Factors

  • Freud's Theory: Suicidal behavior can be viewed as aggression turned inward.

  • Menninger's Theory: Involves three desires:

    • Wish to kill.

    • Wish to be killed.

    • Wish to die.

  • Beck's Theory: Central emotional factor contributing to suicidality is hopelessness.

  • Recent Theories: A combination of suicidal fantasies and significant personal losses can lead to suicidal behavior.

Protective Factors

  • Coping Skills: Abilities in problem-solving and conflict resolution are important.

  • Family and Community Support: Strong relationships can offer protection against suicidal tendencies.

  • Sense of Belonging: A strong identity and self-esteem can be protective.

  • Future Goals: Having identifiable goals can reduce risk.

  • Leisure Activities: Engaging in enjoyable activities offers constructive time utilization.

  • Healthcare Relationships: Access to ongoing medical and mental health care promotes protective factors.

  • Clinical Care: Effective management of mental, physical, and substance use disorders is crucial.

  • Access to Support: Availability of clinical interventions encourages help-seeking behavior.

  • Restricting Lethal Means: Limiting access to methods of suicide can decrease risk.

  • Life Meaning: Finding meaning in life significantly contributes to protective factors.

Cultural Factors

  • Connection to Culture and Religion: Cultural, spiritual, and religious beliefs provide support systems:

    • African Americans: Relies on the role of religion and extended family.

    • Hispanic Americans: The importance of the Roman Catholic faith and extended family.

    • Asian Americans: Involvement in religions that emphasize interdependence within society is protective.

Societal Factors

  • Legislation:

    • Oregon’s Death with Dignity Act (1994): Allows terminally ill patients to opt for physician-assisted suicide.

    • Similar laws in Washington State, Netherlands, Belgium, and Switzerland focus on assisted suicide for severe, non-terminal suffering.

Application of the Nursing Process

  • Assessment:

    • Observe verbal and nonverbal cues.

    • Overt Statements: Direct expressions of suicidal ideation.

    • Covert Statements: More indirect hints about suicidal feelings.

    • Assess the lethality of the suicide plan using tools such as the Columbia-Suicide Severity Rating Scale.

Lethality Assessment

  • Aim: Predicting the likelihood of suicide

  • Direct Communication: Engaging with the client about intentions.

  • Evaluation of Plans: Consider details like time, place, means, and personal intent to act on the plan.

  • High-Risk Indicators: Specific plans detailing time, place, and means pose a greater risk.

Box 23-6: Lethality of Suicide Methods

  • Less Lethal Methods:

    • Wrist cutting, house gas inhalation, nonprescription medications (excluding aspirin and acetaminophen), tranquilizers.

  • Highly Lethal Methods:

    • Firearms, jumping from heights, hanging, drowning, carbon monoxide poisoning, overdose of barbiturates and sleeping pills, high doses of aspirin/acetaminophen, car crash, exposure to extreme cold.

Case Study

  • Scenario: Concern for a friend post-breakup; assess suicidal ideation.

Columbia-Suicide Severity Rating Scale

  • Initial Screening Questions:

    1. Wishing to be dead or to sleep without waking.

    2. Thoughts of killing oneself.

  • Follow-up if yes to Question 2:

    1. Considering methods of killing oneself.

    2. Intent to carry out the plan.

    3. Preparation or actions taken to end life.

Application of the Nursing Process: Diagnosis

  • Diagnosis: Risk for suicide identified.

  • Outcomes Identification: Aim for self-restraint from suicidal actions.

Levels of Intervention

  • Primary: Supportive activities aimed at prevention.

  • Secondary: Treatment methods addressing the acute suicidal crisis.

  • Tertiary: Support for survivors left behind after suicide, minimizing trauma and guilt.

Interventions

  • Teamwork: Collaborative safety measures for patients.

  • Counseling and Health Teaching: Provision of education and therapeutic interventions.

  • Case Management: Coordinating care among services.

  • Pharmacological Interventions: Use of SSRIs, benzodiazepines, mood stabilizers, and atypical antipsychotics.

"Contracting for Safety"

  • Research Basis: Lacks strong research support; not a substitute for comprehensive assessment.

  • Guidelines: Do not rely solely on a "no-harm contract" during assessments.

Personal Safety Plan

  • Patient-Centered: Individual commitment to strategies for safety and treatment.

  • Includes coping strategies, assistance avenues, and preliminary safety plans prior to suicidal thoughts.

In-patient Hospitalization

  • Demonstrates the safety plan's usage; recognizing warning signs and triggers.

  • Continuous evaluation and modification of the safety plan, especially upon discharge.

Advanced Practice Interventions

  • Types of Interventions:

    • Psychotherapy, psychobiological interventions, clinical supervision, and consultation for high-risk clients.

Audience Response Questions

  • Question 1: Identifies the patient at risk based on history.

  • Evaluations: Consider improvement signs and reassess suicidality amidst observed changes.

Self-Injurious Behavior (SIB)

  • Definition: Maladaptive behaviors; physical self-harm without intention to die.

  • Purpose: A mechanism to restore inner balance under stress.

SIB Classification

  • Types:

    • Stereotypic, Major, Compulsive, Impulsive.

Nonsuicidal Self-Injury

  • Scope includes prevalence, comorbidity, and etiology.

    • Consider biological, cultural, and societal factors influencing the incidence of self-injury.